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John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The Health Information Technology for Economic and Clinical Health Act’s (HITECH) major goal is to increase EHR adoption. The major questions are “Is it enough?” and “Will it work?” Let’s take a look at each of these questions.

Is it enough?Background:
The Health Information Technology for Economic and Clinical Health Act (HITECH) provides $18 million in incentives through Medicare and Medicaid reimbursements. Starting in 2011, physicians who show that they are “meaningfully” using health IT would be eligible for $40,000 to $65,000, and hospitals would be eligible for several million dollars. The incentives would be phased out over time, with penalties in place by 2016.Answer:
$40,000 seems like a large chunk of money for EHR. Of course, we have to remember that it’s spread out over 5 years, but $40k isn’t insignificant. Sure, many EHR out there cost $200k plus to implement. However, not all of them are this expensive. In fact, I’d say that the EHR market has shifted from mostly high priced EHR to more moderately priced EHR with unique pricing structures.

The possible problem with the HITECH legislation is that we still don’t know how HHS will interpret what a certified EHR will be. If they say it’s a CCHIT certified EHR, then $40k might not be enough reimbursement. If they create a better standard for certification which will include specialty EHR and smaller but effective EHR software, then $40k is probably enough for many doctors to turn the corner and implement an EHR.

Will it work?
My simple answer is No.

Let me explain my reasoning. I think we all underestimate the biggest reason why most doctors don’t want to implement an EHR. Many doctors just don’t want to change. Sometimes this is related to fear (see colleagues failures). Sometimes it’s related to retirement pending. Most significant is they just don’t see how it benefits them (the doctor). Throwing a little cash at them isn’t going to change their desire not to change. They’ll just find another excuse. They’re preferred EHR isn’t “certified” might be a good one.

We also have to remember that this isn’t cash up front to pay for the EHR. It comes in the form of Medicare and Medicaid reimbursements that you hope you’ll qualify for after having spent money, time and energy (the oft forgotten element in an EHR implementation) implementing an EHR. If this was cash up front I might have a different point of view. However, far too many doctors have been screwed over (excuse the descriptive language) by Medicare and Medicaid reimbursement. Let’s not be surprised if many doctors don’t believe that they’ll ever see any of this extra Medicare and Medicaid reimbursement. If you still think this is far fetched, just do some research on doctors’ experience getting this same type of reimbursement from the ePrescribing initiative.

Add in the increased “paperwork” otherwise known as reporting requirements to receive the reimbursement and hopefully you’ll have an idea of why I think this won’t work. Most doctors want to see patients. They don’t want to deal with extra paperwork which includes researching an EHR. This is government aid were talking about and that’s pretty much synonymous with red tape.

Conclusion
I’m not trying to be a pessimist, but I am trying to be realistic. I just don’t see this new stimulus package having the desired effect on EHR adoption. More importantly, I hope that doctors take their time in selecting an EHR properly and aren’t swayed by the dollar signs EHR vendors will certainly be waving for them. Another set of poorly selected and implemented EHR will set back EHR adoption for years to come.

Luckily, I’m optimistic that most doctors have seen enough failures around them that they’ll tread lightly and not rush into EHR implementation.

19 responses to "Effect of Stimulus Package on EHR Adoption"

[…] bound to be a lot of winners. The money has to go somewhere. I previously posted how I think that EHR adoption won’t significantly increase because of HITECH. However, there will be some BIG winners from this legislation. Lets’s take a quick look at a […]

If we put the financial reimbursement aside for a moment, the question becomes to a degree, is there inherent value in a practice shifting to EHR, for the practice? …for the patient? Assuming there is (maybe a big assumption), how do you get practioners and practice administrators to change their mindset and behaviors, and look at EHR as a positive thing. I think that in the long run this is the bigger hurdle.

Lee White,
Your comment really made me laugh, because I’m currently working on a post that I’ve titled “HITECH’s Fundamental Assumption” which basically will talk a bit about whether the assumption is true or not.

As you can probably infer from my post above, I agree that changing the mindset of practitioners is the much bigger challenge. I’ve suggested at other times that maybe the new generation of internet users are still in medical school or at least not in positions to be able to effect this change from the inside. So, possibly time will be the biggest healer of all.

I’ve posted on a couple blogs about this recently, but I think it bears repeating. One of the biggest barriers to adoption is usability. The user experience of the system trumps implementation costs, security, privacy, and systems integration when it comes to barriers to adoption. User Centric (a Chicago-based user research firm) just published a white paper on “How to Select an Electronic Health Record System that Healthcare Professionals Can Use.” This white paper reviews implementation and procurement guidelines for EHRs and found that emphasis on the usability of these systems is low. The focus is on integration and technology with little to no attention on the actual usability of the system. User Centric took a look at dozens of Requests for Proposal and procurement guidelines for EHRs to learn how usability was addressed and found only THREE addressed user experience. The complete white paper is here: http://www.usercentric.com/publications/2009/02/ehr/

“If they say it’s a CCHIT certified EHR, then $40k might not be enough reimbursement.”
– This is true for many of the legacy systems but for newer Internet-based systems such as ours (Sevcoity), you can get a certified system for 5 years for less than the reimbursement. And yes, that includes all the costs other than Internet (which most practices already have) and the PCs (which they usually have as well).
“Many doctors just don’t want to change.”
– True but we are also seeing this change. Ironically, the expensive legacy systems are often also the hardest to use and to adapt to your practice. Newer systems tend to be more flexible and have higher adoption/usage rates. We experiened 80% sales growth from 2007-2008 and have providers constantly saying “I don’t know why I didn’t do this sooner.” A good EHR system, well implemented brings sanity to an office and does improve the bottom line.

As a result, I think the stimulus will work. It will get many of the fence sitters to take the plunge. They will purchase the more flexible and affordable systems. The vendors will have to listen to keep their business, the products will continue to improve and more providers will come.

Pamela,
Isn’t it really sad that usability of an EHR system isn’t getting the attention it deserves. My fear is that a bunch of doctors will jump on the gravy train and implement unusable EHR software setting EHR adoption back farther than we were before.

Catherine,
Nice to know there are some newer products that are CCHIT certified. Let me ask you honestly, how much of what you had to do to be CCHIT certified was basically “bloat” that you wouldn’t have done if it weren’t for the certification? How much time did you spend on just the process of certification that could have been done creating innovative changes to your product?

I don’t know Sevocity at all, but I am afraid that doctors won’t know the difference between an unusable legacy software that is CCHIT certified and those others that might work great.

Plus, I’m even more concerned about many impressive EHR that won’t be certified, but could change doctors and patients lives.

I am happy to hear about the change in many doctors towards implementation. The EHR software has matured incredibly over the past couple years. I’m guessing in a couple years we’ll see 10 times the innovation in this space and then we’ll see higher EHR adoption. However, it won’t be related to the stimulus as much as innovation by EHR software vendors.

Q: How much of CCHIT has ben bloat?
A: Good question. I would estimate 75% of the items but less (50%) of the time. The difference has largely been ePrescribing which was probably 25% of the items (the good part!) and 50% of the time. However, I think a lot of vendors had trouble with the audit trail requirements (which I also think are good requirements) but we already had that functionality.
Q: How will doctors know the difference between unusable CCHIT legacy software and what works great?
A: A few articles are starting to appear on usability and this is really what you are talking about. We have some great posts on our Blog about usability and how to make sure you achieve it. There isn’t enough room here for all our ideas so I will mention the 2 that I think are most important: 1) define and prioritize what usability means to you – its not the same for everyone and 2) test drive the software in a production environment. Many vendors won’t let you – ask yourself why.
Q: What about vendor lock-in and how that prevents vendors from really listening?
A: Unfortunately true with Legacy systems – why you will find so many sitting in a coat closet unused. With newer Internet systems this is changing. The provider can turn it off or switch with no guilt pangs of the thousands invested. These vendors also know that their revenue stream depends upon customer satisfaction. The complete answer would be data standards that would make EHR data more portable. Continuity of Care Document and/or a better focus on this by CCHIT (or whatever body provides the certification) may be answers.

While I feel bad for some of the vendors who have not become certified and I agree some of CCHIT is bloat, it is not that expensive or hard to do in the scheme of things and I would worry about the viability of a company that claims they don’t have the resources to pursue CCHIT each year. This is just my personal opinion. That said, I agree that CCHIT’s current requirements are probably overstated.

Catherine,
Thanks for the insight on CCHIT bloat. Interesting to think about percentages.

As far as vendor lock-in. I’m not just talking about the legacy systems “thousands invested.” Every EMR system out there requires much more investment beyond dollars and cents. Training, emotional involvement, learning curve, process planning, code creation, configuration, etc all make the idea of switching EMR after implementation an unbearable thought. Not to mention pulling out the data stored in an existing EMR and moving it to a new one.

Takes a really brave soul to even consider switching from one EMR to another IMHO.

I don’t feel bad for vendors that aren’t CCHIT certified. They made a business decision and you did too. The issue usually isn’t that an EMR company doesn’t “have the resources to pursue CCHIT each year.” My feeling is that most EMR companies that choose not to pursue CCHIT certification have chosen to just use those resources in other ways. Now if the EMR company hasn’t used those CCHIT certification dollars to really innovate the product, then you should be worried.

The “momentum” of an EMR comapny’s development is an important factor I think that many should consider when selecting an EMR. You want an EMR that is constantly improving their product and can do so quickly and easily. The challenge is that momentum is hard to guage for someone who prefers looking down throats.

Also, let’s also remember all the really specialized EMR software that aren’t doing CCHIT certification, because it wouldn’t make sense for their specialty. Another good reason not to use CCHIT as a criteria for EHR selection and government money.

I agree that switching EHRs would be very very hard. However, the vast majority of existing EHR owners that contact us are owners but not users – they found the EHR so difficult that they never really used it. One solution is a money back guarantee. As a vendor its a scary proposition but it does help the provider make sure they’ve made the right decision before they’ve spent too much time or money. We offer 60 days, which we believe is enough time to know whether or not it is for you. We do require the provider to have completed 100 encounters so we know they gave it a real try. While this is still a time investment for the provider, 2 months of some extra time and training may be worth it to avoid spending a ton more time and money on something that is not for them.

Still amazes me how many have paid so much for an EHR and never used it. Makes me sick to think about.

The money back guarantee is interesting. Definitely takes faith in your product to offer that. However, the good will you build in the EHR community is probably of as much value. By giving a money back guarantee you avoid having a failed implementation at a doctor’s office spreading bad information about your company.

It’s a start. There’s plenty of room to be a pessimist here. I applaud President Obama to at least recognize the need for moving forward. Yes, there will be a lot of “elbowing” going on for sales by various vendors, however using CCHIT as at least a basis for funding seems reasonable. There have been several iniatives, private grants, government grants, insurance company proprosals that have been available over the past few years, (not for Illinois Doctors) but they’ve been limited to certain states, and certain markets.

At least now, physicians and physician practices of areas, especially ours (Illinois), embrollied in controversy, scandals, red ink, can move forward in our efforts to improve patient safety, effiency and quality care that an excellent EMR can afford. And by the way, this will decrease Health Care costs.

I don’t think I’m a pessimist. I think I’m just trying to be realistic about the affect the HITECH act will have on EHR adoption. In fact, I think I’m a strong optimist about the future benefits of EHR adoption. Otherwise, I wouldn’t be working in the field.

I can agree that “using CCHIT as at least a basis for funding seems reasonable” when you don’t understand much about CCHIT certification. From a high level (ie. Obama) it makes sense that there is an existing certification funded by large amounts of government money, then it should be used. I can appreciate this decision making, even if it’s a bad idea.

Check out some of my other posts about CCHIT and you’ll see some reasons why using CCHIT as the HITECH act certification criteria is a bad idea which could set back EHR adoption.

I hope that all physicians and practices can move forward regardless of the various controversies and funding and see the benefits of EHR. At least we can both agree that EHR has benefits. We’ll leave discussion of the finer points of the benefits offered for another time.

The first stumbling block after removing the financial barriers is the notion that EHRs speed up documentation and eliminate transcription. Though many provide tools to speed up ones own typing, via templates and drop down menus, it will rarely be faster than dictating. EHR systems are electronic filing cabinets, not dictation substitutes. To their credit, they do prompt and ease the inclusion of more data in a particular encounter note. But, much of the included information constitutes “pertinent” negatives that convolute real information retrieval. Which then adds the additional tasks of adding standout or summary sections in ones documentation so that the doctor viewing the note can skip the “pertinent negatives” and read the section of the note that one would have dictated prior to the implementation of EHR.

This is the greatest cause of failure to implement in my opinion. Older practitioners never really adopted or worried about documentation requirements for a 99214 and continue to spend 4 minutes in an exam room and chart a 3 line note. They don’t want to re-enter a PMH, ROS, ALL, Meds etc already completed on the patients written encounter form. then chart 4 pages of pertinent negatives that later complicate data retrieval, (did that patient have crackles in the left or right lower quad? ).
Then, while the government is concerned about interop communication, the doctor wants integration within his/her own office, into billing and diagnostics so that the act of taking an in-office-x- ray automates a charge on the patients bill and a prompt for a report within the exam note. The cost of this integration is overlooked until to late and requires updating 1-4 times per year.
Lastly, the cost of training is a deal breaker. The 44k offered does not actually make up for the 1-2 weeks in which a doctor must shut down an office, while continuing to pay staff, then run at 1/2 to 1/4 productivity for weeks or months until the system can be utilized at speeds anywhere close to the speed of a the doc that sees 6-10 patients per hour, 2 of which are new patients each warranting 2 -10 lines of dictation. This practice style was widely adopted with the advent of HMO’s encouraging more patients at lower reimbursements. There is now no financial incentive for slowing down and completing that level of documentation that now takes the time that would have been spent on two more billable office visits.–Not My practice mind you but certainly common.

[…] That’s the basics of the EMR stimulus package. I’ll follow up this post tomorrow with a look at what it takes to show “meaningful use” of an EHR and some thoughts on what effect this stimulus package will have on EHR adoption. […]

[…] Effect of Stimulus Package on EHR Adoption – I think this was a somewhat pivotal post for me. I sadly articulated the lack of value of the EMR stimulus money and how I believed that it wouldn’t have the desired effect on EMR adoption. However, it also helped me to realize and conclude how important it is for doctors to take their time selecting the right EMR and not be distracted by the EMR stimulus dollars. Something that I’ve repeated a lot the past year and a half. Related ArticlesEffect of Stimulus Package on EHR Adoption […]

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